Middle Level

 1. 

Bullying is when a person does something to hurt another person's body or feelings on purpose.

ABOUT YOU

What grade are you in?
         
 Sixth
 Seventh
 Eighth
 
 2. Do you feel safe at school?
         
 Yes    No
 
 3. Do you feel welcome at school?
         
 Yes    No
 
 4. Is there an adult at school you talk to when you have a personal problem and need help?
         
 Yes    No
 
 5. Have YOU been bullied at school?
         
 Yes    No
 
 6. Have YOU been bullied verbally (someone says mean things to you)?
         
 Yes    No
 
 7. Have YOU been bullied physically (someone hurts your body)?
         
 Yes    No
 
 8. Have YOU been bullied emotionally (someone hurting you by being mean: for example; leaving you out, getting others to dislike you or exclude you)?
         
 Yes    No
 
 9. Have YOU been bullied through technology (someone sends you mean or threatening texts, posts or messages)?
         
 Yes    No
 
 10. If YOU have been bullied at school, HOW OFTEN has this happened?
         
 Never
 Sometimes
 A Lot
 
 11. If YOU have been bullied WHERE has this happened? * Choose the one where most of the bullying happens.
         
 My Classroom
 The Hallway
 The Cafeteria
 The Bathroom
 The Bus
 Locker Rooms
 I have not been bullied
 Other
 
 12. If you have been bullied, WHEN has this happened?
         
 Before school
 During school
 After School
 I have not been bullied
 
 13. If YOU are bullied do you tell your parent or guardian?
         
 Yes
 No
 I have not been bullied
 
 14. If YOU get bullied what do you do? * Choose what you do most often.
         
 I have not been bullied
 Nothing/Ignore it
 Stay away from the person
 Tell the person to stop
 Bully the person back
 Talk to an adult at school
 Tell my family at home
 
 15. Do YOU bully others at school?
         
 Yes    No
 
 16. If YOU bully others at school how often do you do this?
         
 Never
 Sometimes
 A Lot
 I do not bully others
 
 17. How have YOU bullied others? * Choose what you do most often.
         
 Verbally (hurting with words)
 Physically ( hurting with hands or feet)
 Emotionally (hurting with meanness)
 Cyber-bullying (hurting through technology)
 I do not bully others
 
 18. If YOU bully others WHERE does this happen? * Choose the place where you bully others most often.
         
 My Classroom
 The Hallway
 The Cafeteria
 The Bathroom
 The Bus
 Locker Rooms
 I do not bully others
 Other
 
 19. Why do YOU bully others? * Choose the one that is most often true for you.
         
 I'm just joking around.
 To get attention from my friends and teachers
 The person bothers me
 It makes me feel powerful and in control
 I do not bully others
 
 20. ABOUT OTHERS

How often do you see OTHERS get bullied at school?
         
 Never
 Sometimes
 A lot
 
 21. Have you seen OTHERS be bullied verbally (saying mean things)?
         
 Yes    No
 
 22. Have you seen OTHERS be bullied physically (hurting someone's body)?
         
 Yes    No
 
 23. Have you seen OTHERS be bullied emotionally (left out, excluded on purpose)?
         
 Yes    No
 
 24. Have you seen OTHERS be bullied through technology (texting, messaging, Facebook, etc.)?
         
 Yes    No
 
 25. WHEN do you see OTHERS get bullied at school?
         
 Before school
 During school
 After school
 I don't see others get bullied
 
 26. WHY do YOU or OTHERS get bullied at school? * Choose the reason you think is true most often.
         
 Skin Color
 Look different
 Act different
 Talk different
 Perceived sexual orientation
 I don't know
 
 27. If you see OTHERS get bullied at school what do you do? * Choose what you do most often.
         
 I don't see others get bullied
 Nothing/ignore it
 Tell the bully to stop
 Join in the bullying
 Try to help the person who is being bullied feel better
 Tell an adult in school
 Tell my parent/guardian
 
 28. If you see OTHERS get bullied at school WHERE does this happen? * Choose what you have seen most often.
         
 My Classroom
 The Hallway
 The Cafeteria
 The Bathroom
 The Bus
 Locker Rooms
 I do not see others get bullied
 Other
 
 29. ABOUT SCHOOL STAFF

What do adults at school do if they see you or others being bullied at school? * Choose what you see happen most often.
         
 Nothing/Ignore it
 Tell the bully to stop
 Tell the person being bullied to ignore it
 Tell the person being bullied not to tattle
 Give the person bullying someone a consequence
 
 30. Do you think adults at school care about stopping bullying in your school?
         
 Yes    No
 
 31. YOU CAN HELP

List the first and last name and the grade of students who are being bullied.
         
    
 
 32. List the first and last name and the grade of students who are bullying others.